How well do you know the Wizard of Oz? Chances are you
remember that Dorothy is accompanied by the Lion, Tin Man and Scarecrow, but do
you remember which one she meets first? Does the Lion help to bring the Tin Man
to life? Was it the Scarecrow who tempted the Lion from the forest? Sequence is
essential to the story.
Similarly, our life stories develop around causes and
effects. You could probably guess that risky sexual behaviors, substance abuse,
and depression go together. But which of these lions, tigers and bears are
causes and which are the results?
It may seem like a silly question: if risky sex, drugs and
depression all eventually tend to get mashed up together, who cares which one comes
first? But in fact, this is one of the most important questions in substance
abuse treatment and recovery. Think of it like the relationship between heart
disease and chest pain: if you treat the pain instead of the underlying cause
of heart disease, the pain will come back again and again.
What if, as popular opinion holds, depression is a cause of
substance abuse? Do depressed people "self-medicate" with sex or
substances in order to feel better, only to find themselves eventually addicted?
In that case, treating the substance abuse by itself is like treating chest
pain – eventually depression will bring back the symptom of addiction, and the
individual will relapse again and again.
Now imagine addiction is the cause and depression is the
symptom. In this case, treating addiction kills both birds with one stone –
with the cause of addiction gone, so is the symptom of depression. Sure there's
some grey area here. For example, maybe it's impossible to treat depression
until an addiction is under control. But the heart of the question remains:
what is at the root of this combination of challenges you wouldn't wish on the
wickedest witch?
The answer comes from
of 18,924
teenagers, the population in which so many of these challenges start. Which
teenagers abstained, who experimented, and who were heavy users? Who was
depressed? And how did these behaviors change when measured one year and again
the next?
It turns out that teens who experiment with sex and drugs
are likely to be depressed a year later. But teens who are depressed are no
more likely to have experimented with risky sex and drugs the next year. So
much for self-medicating the symptoms of depression; instead, it seems that risky
behaviors come first and depression follows.
However, beyond this important headline, results get trickier.
For example, both experimenting and heavy-use of drugs and/or sex among girls
led to depression. But among boys, it was only heavy using that increased
depression a year later – for some reason, these boys were more resilient to
experimentation than girls. And in drug-abstaining girls, depression made them even
less likely to experiment a year later, but in girls who were already
experimenting, depression made them more likely to transition into heavy use — as
if depression further insulated abstainers from temptation and tipped
experimenters over a self-destructive cliff.
Of course there are people who buck the trend. There are
many individuals who are depressed first and find substance abuse or risky sex
second. And there are people with at-risk or even heavy-use behaviors who never
become depressed.
The truth is, despite what science shows is usually the case
we can rarely know with certainty at the onset of treatment what triggers
depression, substance abuse, and risky sexual behavior. And it’s not worth
guessing which is the chicken and which is the egg – the consequences are too
extreme. Instead, when presented with co-occurring disorders, we find it’s best
to treat each as a cause, and treat each psychological and psychiatric disorder
concurrently with addiction. Only by peeling back the layers of symptoms until
discovering the causes of risky, destructive and terrifying behaviors, can we treat
these issues in a way that is truly long-lasting.
